New for Aspiring Doctors, the People Skills Test

GARDINER HARRIS,
NY Times 10 July 2011

ROANOKE, Va. — Doctors save lives, but they can sometimes be insufferable know-it-alls who bully nurses and do not listen to patients. Medical schools have traditionally done little to screen out such flawed applicants or to train them to behave better, but that is changing.

At Virginia Tech Carilion, the nation’s newest medical school, administrators decided against relying solely on grades, test scores and hourlong interviews to determine who got in. Instead, the school invited candidates to the admissions equivalent of speed-dating: nine brief interviews that forced candidates to show they had the social skills to navigate a health care system in which good communication has become critical.

The new process has enormous consequences not only for the lives of the applicants but, its backers hope, also for the entire health care system. It is called the multiple mini interview, or M.M.I., and its use is spreading. At least eight medical schools in the United States — including those at Stanford, the University of California, Los Angeles, and the University of Cincinnati — and 13 in Canada are using it.

At Virginia Tech Carilion, 26 candidates showed up on a Saturday in March and stood with their backs to the doors of 26 small rooms. When a bell sounded, the applicants spun around and read a sheet of paper taped to the door that described an ethical conundrum. Two minutes later, the bell sounded again and the applicants charged into the small rooms and found an interviewer waiting. A chorus of cheerful greetings rang out, and the doors shut. The candidates had eight minutes to discuss that room’s situation. Then they moved to the next room, the next surprise conundrum and the next interviewer, who scored each applicant with a number and sometimes a brief note.

The school asked that the actual questions be kept secret, but some sample questions include whether giving patients unproven alternative remedies is ethical, whether pediatricians should support parents who want to circumcise their baby boys and whether insurance co-pays for medical visits are appropriate.

Virginia Tech Carilion administrators said they created questions that assessed how well candidates think on their feet and how willing they are to work in teams. The most important part of the interviews are often not candidates’ initial responses — there are no right or wrong answers — but how well they respond when someone disagrees with them, something that happens when working in teams.

Candidates who jump to improper conclusions, fail to listen or are overly opinionated fare poorly because such behavior undermines teams. Those who respond appropriately to the emotional tenor of the interviewer or ask for more information do well in the new admissions process because such tendencies are helpful not only with colleagues but also with patients.

“We are trying to weed out the students who look great on paper but haven’t developed the people or communication skills we think are important,” said Dr. Stephen Workman, associate dean for admissions and administration at Virginia Tech Carilion.

Dr. Charles Prober, senior associate dean at the Stanford University School of Medicine, said Stanford always valued social skills in students — particularly the ability to work collaboratively with colleagues and establish trust with patients — but did not have a reliable way of ferreting these skills out until adopting mini interviews.

The system grew out of research that found that interviewers rarely change their scores after the first five minutes, that using multiple interviewers removes random bias and that situational interviews rather than personal ones are more likely to reveal character flaws, said Dr. Harold Reiter, a professor at McMaster University in Hamilton, Ontario, who developed the system.

In fact, candidate scores on multiple mini interviews have proved highly predictive of scores on medical licensing exams three to five years later that test doctors’ decision-making, patient interactions and cultural competency, Dr. Reiter said.

A pleasant bedside manner and an attentive ear have always been desirable traits in doctors, of course, but two trends have led school administrators to make the hunt for these qualities a priority. The first is a growing catalog of studies that pin the blame for an appalling share of preventable deaths on poor communication among doctors, patients and nurses that often results because some doctors, while technically competent, are socially inept.

The second and related trend is that medicine is evolving from an individual to a team sport. Solo medical practices are disappearing. In their place, large health systems — encouraged by new government policies — are creating teams to provide care coordinated across disciplines. The strength of such teams often has more to do with communication than the technical competence of any one member.

“When I entered medical school, it was all about being an individual expert,” said Dr. Darrell G. Kirch, the president and chief executive of the Association of American Medical Colleges. “Now it’s all about applying that expertise to team-based patient care.”

The nation’s 134 medical schools have long relied almost entirely on college grades and a standardized test, the Medical College Admission Test, to sort through more than 42,000 applicants for nearly 19,000 slots.

One-on-one interviews are offered but provide poor assessments of a candidate’s social skills because they reflect only one person’s view, often focus on academic issues and elicit practiced responses to canned questions like “Why do you want to become a doctor?”

Administrators at Virginia Tech Carilion say teamwork has become so essential to medicine that the school not only chooses its students based on their willingness and ability to collaborate effectively, but also requires students to take teamwork classes.

The school invests more effort in honing students’ social skills than almost any other and requires that students undertake community projects with nurses and other health professionals, who are even invited to school dances.

“Our school intends to graduate physicians who can communicate with patients and work in a team,” said Dr. Cynda Ann Johnson, the dean of the Virginia Tech Carilion School of Medicine, which opened in August 2010. “So if people do poorly on the M.M.I., they will not be offered positions in our class.”

The problems these efforts address are profound. Dr. Leora Horwitz, an assistant professor of medicine at Yale, recalled an incident in her residency at Mount Sinai Medical Center in New York when a medical student marched into the hospital room of an elderly minister surrounded by his wife and several parishioners.

“And he announces in front of everyone: ‘We found the reason for your problem. The syphilis test is positive,’ ” Dr. Horwitz said. “It was a devastating event for the family and the whole church, and this student had no sense for that.”

Even more dangerous is when poor communication becomes so endemic that the wrong operations are performed. A 2002 study published in The Annals of Internal Medicine of one such incident found that the patient, doctors and nurses went along with the mistaken treatment because they were used to being kept in the dark about medical procedures. A survey by the Joint Commission, a hospital accreditation group, found communication woes to be among the leading causes of medical errors, which cause as many as 98,000 deaths each year.

Using mini interviews to help address these problems, though, left applicants at Virginia Tech Carilion wide-eyed. One said one of her interviewers hated her, so she was thrilled to talk to others. Another said the system was unfair because some of the situations were drawn from news events she had not followed.

Of the 2,700 applications received by the school over the past year, admissions officers selected 239 to participate in mini interviews conducted over six weekends from August through March. The school has 42 positions in each class. Virginia Tech Carilion trained 80 people to be interviewers, including doctors and businesspeople from the community.

Andrew Snyder, 25, was clearly nervous when the bell rang the first time, but he seemed to relax as the process continued and was smiling by the end. Mr. Snyder said he loved moving from room to room and being asked to discuss some of medicine’s thorny problems. He was accepted and plans to attend Virginia Tech Carilion in August.

“I thought the whole process was more geared toward problem-solving than to me talking about who I was as an applicant,” he said. “And I liked that.”

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